Adolescents and HIV: Rates, Risk and Intervention Opportunities Katrina Kubicek, MA, PhDc Presentation to the Black AIDS Institute and UCLA HIV Science Academy August 28, 2013

This is a developmental stage of development What is Adolescence? This is a developmental stage of development Age range varies, but generally thought to begin with the pubescent years around the age of ten and continues up until physical maturation is reached around the end of the teenage years. For the duration of this time, significant developments happen with regard to sexual and physical development as well as cognitive changes The World Health Organization (WHO) defines ‘‘adolescents’’ as individuals 10–19 years of age, and ‘‘youth’’ as 15–24 years of age

Emerging Adulthood Developmental period distinct from adolescence – typically defined as years 18-25 Important distinction from adolescence in that this is often the first time youth live on their own and form more lasting intimate relationships Research indicates that this period may have increased risk for substance use and sexual risk behaviors

HIV among Adolescents CDC estimates that youth aged 13-29 account for 39% of all new HIV infections in the United States; 15-29 year olds comprise 21% of the US population Although overall rates of HIV diagnoses remained stable from 2006 to 2009, HIV diagnosis rates increased for youth aged 15–19 and 20–24 years over the same period Approximately 68,600 young people aged 13–24 years were living with HIV infection at the end of 2008; of those, nearly 60% did not know they were infected. Some youth are more affected than others Young men who have sex with men – especially young men of color Adolescent minorities

HIV among Adolescents

HIV Risk among Adolescents 47% have had sexual intercourse at least once. 40% of currently sexually active students did not use a condom the last time they had sex. 15% have had four or more sex partners. 6% had sexual intercourse for the first time before age 13. 2% have injected illegal drugs at least once. Sexually transmitted infection rates are highest among adolescents

HIV Testing in Adolescence The 2011 Youth Risk Behavior Survey found that 13% of 9th–12th grade students had ever tested for HIV 46% of high school students have had sexual intercourse HIV testing varies by factors such as: Sexual experience Race/ethnicity Among sexually active students who did not use a condom the last time they had sex, 30% had ever been tested for HIV HIV testing is recommended by CDC as a routine part of health care for adolescents and adults aged 13–64 years for reducing the spread of HIV

Risk Factors for Adolescents Substance use – club drugs (e.g., methamphetamines, cocaine, ecstasy) other drugs and alcohol linked to unprotected sex Dating violence – link to HIV risk behaviors among adults and adolescents involved in partner violence Impulsivity - sensation seeking, rises dramatically during adolescence and increases risks to healthy development Peer influences – perceptions of what peers do often more important than actual behaviors of peers Education and awareness - Research has shown that a large proportion of young people are not concerned about becoming infected with HIV 24% of high school students had 5 or more drinks in one day in the past 30 days and 21% had smoked marijuana in past 30 days

Special Populations Homeless Youth Young men who have sex with men (YMSM) African American YMSM Ballroom community African American female adolescents African American male adolescents

Homeless Youth Rates vary between 5% - 17%; even lowest of this range is about twice that of the prevalence rates of non-homeless youth High levels of “substance use disorders” among homeless youth Homeless youth may be involved in higher risk activities such as injection drug use and sex exchange Many homeless youth have experienced abuse – particularly sexual abuse Strategies that may decrease risk include the elimination of need to rely on illicit activities for income, provision of basic needs, increased outreach efforts, and early identification of and protection from childhood sexual abuse

Young Men Who Have Sex with Men (YMSM) HIV rates among YMSM continue to rise, particularly among young men of color Among adolescent males ages 13-19, about 91% of all diagnosed HIV infections are from male-to-male sexual contact

Specific Risks for YMSM Strong relationship between drug use and HIV transmission Experiences of harassment, violence and victimization can lead to poorer mental health and HIV risk-related behaviors Societal and familial homophobia contribute to mental health and well-being of YMSM Limited resources such as sexual education and outreach for HIV prevention efforts Additional stressors can increase risk for involvement in risky behaviors Social media and mobile phone apps may present additional risk

HIV Among YMSM by Race/Ethnicity

African American Young Men Who Have Sex with Men Higher HIV rates among African American YMSM but sexual risk and substance use rates are similar or lower than their White counterparts Racism and homophobia affect HIV risk Less “safe spaces” African American YMSM tend to have sexual partners of same racial/ethnic group – affects the HIV reservoir

House and Ball Communities Derived from Harlem Balls of the 1920s, underground celebrations and competitions House and Ball communities work in tandem to develop and support a community involving primarily African American and Latino individuals of diverse sexual and gender identities Houses are different groups of individuals that compete against each other during Balls Balls are underground events involving competitions focused around dance, athletics, and gender expression. Houses are identified as having a sense of family, friendship, and support and have a Mother and/or Father The limited research with these communities suggests HIV is a major public health concern

African American Female Adolescents One in four girls (14-19) has an STI; and nearly half (48%) of the African-American girls had at least one STI Despite reporting greater frequency of condom use than their White and Hispanic counterparts, African American female adolescents experience disproportionately high rates of HIV/STIs Younger female adolescents are more susceptible to STIs due to biological factors (e.g., cervical ectopy, maturing immune system) Issues related to higher rates include: Limited partner communication Sex refusal self-efficacy Condom use self-efficacy STI knowledge Research has found that parent–adolescent communication about sex is protective for young African-American females

African American Male Adolescents Of the approximate 19,000 adolescent and young adult males living with a diagnosis of HIV infection, 64% are African American Chlamydia rate among African American males was 12 times higher than that among White males; syphilis rate is 22 times higher 14% of adolescents have had sexual intercourse with four + persons, yet 39% of African American males reported more than 4 partners Among adolescent males, a traditional conception of manhood is associated with engagement in sexual risk behaviors While some cultural or psychosocial factors may affect risk, again, we see that African Americans are exposed to STIs and HIV at higher rates than other groups

The Cascade of HIV Prevention: Linkage to Care Adolescents may experience unique challenges in this arena: Insurance and confidentiality Sense of “invincibility” Maintaining relationships with providers Medication adherence

Promising or Best Practices : Behavioral Interventions Multifaceted approach to HIV prevention, (e.g. individual, peer, familial, school, church, and community programs) is necessary to reduce the incidence of HIV in young people Biomedical Prevention Efforts Examples of Effective Behavioral Interventions Focus on Youth Mpowerment Project AIM SIHLE Street Smart

Summary Adolescents remain a high risk population Young MSM, minority youth and homeless populations represents unique challenges for prevention work Challenge in engaging them in the cascade of HIV prevention Affordable Care Act provides new opportunities to engage youth and young adults Working with parents or other social support systems is important Schools should be integrated into public health efforts Churches and other community centers may also offer important prevention opportunities.

Resources National Resource Center for HIV/AIDS Prevention among Adolescents - https://preventyouthhiv.org/ The Center For Strengthening Youth Prevention Paradigms http://www.chla.org/site/c.ipINKTOAJsG/b.6092439/k.1F71/Center_for_Strengthening_Youth_Prevention_Paradigms__SYPP__HIV_Prevention__AtRisk_Youth__Webinars.htm#.Uhtno-2K6fQ Society for Adolescent Medicine - http://www.adolescenthealth.org//AM/Template.cfm?Section=Home

Contact Information Katrina Kubicek Program Manager – Community, Health Outcomes and Intervention Research Program Children’s Hospital Los Angeles 323-361-8452 kkubicek@chla.usc.edu